In this episode, host Rachel Handley sits down with Dr. Fiona Challacombe, a leading expert in perinatal anxiety and obsessive-compulsive disorder (OCD), to explore the impact of OCD on new and expecting parents. They discuss why new parents are particularly vulnerable to intrusive thoughts, how CBT techniques can effectively treat perinatal OCD, and the importance of dispelling myths around maternal mental health. Fiona also offers practical advice for therapists working with clients presenting with perinatal OCD, including how to approach and adapt exposure therapy sensitively during pregnancy. If you liked this episode and want to hear more, please do subscribe wherever you get your podcasts. You can follow us at @BABCPpodcasts on X or email us at
[email protected]. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow Useful links: Maternal OCD website- https://maternalocd.org/ Perinatal Positive Practice Guide can be found here: https://babcp.com/Therapists/Perinatal-Positive-Practice-Guide A list of all Fiona’s published papers can be found: https://www.kcl.ac.uk/people/fiona-challacombe Books: Challacombe, F., Green, C., & Bream, V. (2022). Break Free from Maternal Anxiety: A Self-Help Guide for Pregnancy, Birth and the First Postnatal Year. Cambridge: Cambridge University Press. Bream, V., Challacombe, F., Palmer, A., & Salkovskis, P. (2017) Cognitive Behaviour Therapy for Obsessive-compulsive Disorder. Oxford: Oxofrd University Press. Challacombe, F., Salkovskis, P. M., & Oldfield, V. B. (2011). Break Free from OCD: Overcoming Obsessive Compulsive Disorder with CBT. Vermilion. Transcript: Rachel and Fiona Challacombe Rachel: Welcome to Let's Talk About CBT Practice Matters, the BABCP podcast for therapists using Cognitive Behavioural Therapy with me, Rachel Handley. Each episode, we talk to an expert in CBT who share insights that will help you understand and apply CBT better to help your patients. Today we're joined by Dr Fiona Challacombe, lecturer and researcher at King's College London and Oxford University. Therapist, author and leading expert in perinatal anxiety and in particular obsessive compulsive disorder or OCD. Over 20 years, her research has examined the impact of perinatal OCD on women and children, including the first randomised control trial of CBT for postpartum OCD, and treatment effects on anxiety and parenting. She's developed and leads a service for parents with anxiety disorders at the Maudsley Centre for Anxiety Disorders and Trauma and is the author of a number of excellent books and manuals on CBT for OCD, and we'll put some links to those in the show notes for people later on. Welcome Fiona. Fiona: Thanks so much for having me. Rachel: It's really, really great to see you, genuinely great to see you, not least because we're long overdue as we've just been talking about pre-recording for a catch up. We go back quite a long way to our, our training days at the IOP with a bunch of brilliant people. Actually, I'm hoping to get some of the others on this podcast. Becky Murphy hopefully will come and talk to us at some point about eating disorders, but loads of great folk that we were really fortunate to train with. And then I feel a certain pride when I read all the things that you've done, it's not really justified, but it's just kind of like a family connection when you've trained together, isn't it? You feel that connection. So, it's just brilliant to have you here and you've been so committed to this work and I know you're really passionate about it. What got you hooked in this field of OCD, personally and professionally? Fiona: Well, I came to training, which does really feel like yesterday, having worked with Alan Stein on this incredible treatment trial for mums with eating disorders, so that really got me very interested in the early parenting field. And I was really lucky when we started training to train with Paul, I think the first person, one of the first people I ever saw had OCD. And, of course, applying the model as a new trainee, it was just miraculous. It works so well. And getting this understanding of the cognitive model and how responsibility works in this context, putting all of these things together has been an amazing journey really, so starting to understand more about OCD, how well the treatments work, and then thinking about parenthood in that context, it makes so much sense that it's a time of increased risk. So I was very lucky as a trainee to do my doctoral research with parents with OCD, and it was mums with OCD with slightly older children, and understanding a little bit from their point of view about the impacts on parenting and so on. But in talking to those mums, and doing their SCID, and asking them about how their OCD started, when it started, really, one after another had said, well, it started during when I had my baby, it started during the perinatal period. And after about the fifth person had said this, I really thought, this is very interesting. I hadn't really heard of perinatal OCD. It wasn't something that was kind of on the radar. Perinatal mental health services were at a completely different point. It just really was before all the transformation stuff. And whilst most of us were aware of postnatal mood changes and so on, the idea that other things could occur at this time was like a really a not well understood idea, but it was really striking. So that's really all of those things together, what kind of brought me to this topic. Thinking about this early stage, why would it be that this perinatal period would be such a time of kind of onset, really, and risk for this problem? Rachel: And you mentioned there, Paul Salkovskis, who I've just recently recorded another podcast with on OCD more generally, which will hopefully be available to folk at the same time as this. And he's been such a great figure in this field, hasn't he? And someone fantastic to work with in your training and we know from him that OCD is a really widespread problem. It's a smaller problem in sense, statistically, than maybe other, mental health problems that people experience, but nevertheless really significant. And when it afflicts women in that perinatal period, it comes at a really vulnerable time for them, doesn't it? And their children. Can you tell us a bit about how significant a problem it is in that period, how often people have that problem, how it impacts them. Fiona: Yeah, so again, we haven't had good data on this really until very recently, there just aren't those big studies, but it does make sense that it's a time of increased risk because I think if you had to make a sort of cocktail for anxiety problems, you would put in a high dose of kind of responsibility, uncertainty, feeling kind of de skilled, and it has all of those elements and all the physical changes and things that kind of make life a lot more challenging. But really the studies hadn't been done. So, we know OCD affects sort of one to two percent of people at any time, a bit more over a lifetime. But there was a fantastic study by Nichole Fairbrother, which gave full kind of diagnostic interviews to a whole cohort of people, as they went through pregnancy into the postnatal period. But what Nichole did was to be really kind of, specific about asking them not only about our common understanding of obsessions and compulsions, and do you check doors and taps and things like that, but also to ask them about infant specific perinatal thoughts, so are you kind of checking the baby excessively and so on. So that study found a very high prevalence, particularly postnatally, so over the whole perinatal period, the whole prevalence I think was about 7%. So, whilst there are, I think, really interesting issues about what's normal and adaptive over that period because most parents can relate to kind of a time of excessive checking and feeling uncertain about things, and all the things that we're very familiar with in terms of the concepts related to anxiety. For a proportion of those people, it clearly is very troubling and impairing and persistent. So, I think there is this genuine increase in prevalence around this time but it can be hard, very hard to sort of distinguish exactly what's what and I think health anxiety probably is fuelling that as well. But it's definitely a time of increased risk. I think we can say that quite confidently, and particularly in the postnatal period and particularly for intrusive thoughts of deliberate harm in that area really is quite distinct to OCD in the sense of it being a very common presentation. You do get in those horrible intrusive thoughts in the normal population in the context of other problems, but that's quite a common presentation postnatally. Rachel: So it sounds like, it's such an important area to be researching, to be thinking about and offering treatment in. And I can really identify with what you're saying about that anxiety around the perinatal period and becoming a parent. I mean, everything else that you have to step up to in life in terms of responsibility like that you normally have to do an exam or, you know, at very least go to a class or someone gives you a job interview and says, yes, you're competent to do this. Suddenly you've got this little person in your arms and you're thinking, who is crazy enough to trust me with this huge responsibility. And people like ourselves, who like to study, probably read lots of books and go to classes and do all of those things. And the advice is often conflicting, isn't I and challenging. And then you add in disturbed sleep and plenty of time to worry and ruminate while you're with this little person who doesn't talk back in the middle of the night. It's not hard to understand why people might be anxious and as you say, what might be normal as well as, more challenging for that. And are there reasons why some people might be more prone to developing OCD, even in that context than others? Are there particular experiences that might lead to particular vulnerability or interpersonal factors that are there? Fiona: Yeah so I think the general vulnerabilities for OCD are of course come into play. So kind of, beliefs about the world, being quite kind of rule bound, ideas about responsibility and those things in that particular situation, as you say, you can imagine why that might be quite tricky. And having had a history of course, is probably the biggest predictor, because I guess, it's a demonstration that those vulnerabilities can be activated in particular situations. But I think, you know, in terms of the characteristics of the pregnancies, I think if you have more complications, if you perhaps have a baby who's got increased vulnerabilities, spending time on the NICU or something like that, it's those factors that you just talked about, but then they're looming even larger. Rachel: For folk that might not know, NICU. Fiona: Yeah, so neonatal intensive care, so it's actually very common for babies to spend a little bit of time, if they're born prematurely or have other complications at birth and so on. I guess it, it's an indicator that there’s a bit of extra help needed, but of course really tricky for parents because you're right in the middle of that medical situation. As I was saying, it's a tricky time to transition to parenthood. But of course, if you're having to go through that and the care is having to be managed by a medical team more extensively. You may have also had a difficult time during birth and labour yourself and all of that. So that's a particularly vulnerable group of parents for all sorts of things. But our research has also indicated that intrusive thoughts are very common in that group, which makes perfect sense as well. Rachel: Absolutely. And then I guess there's other contextual factors which may or may not influence this. So recently there's been a lot of media and news coverage about risk in the perinatal period from risks due to shortages and shortcomings in neonatal care. And then you get the stories about abuse and neglect from parents and carers. Do you find that the frequency and volume of those kinds of stories in any way interacts with maternal anxiety? Fiona: I think inevitably, doesn't it? I think maternity systems are very stressed and understaffed and really difficult places for maternity staff to provide the care that they wish to. At the moment, we're all very aware of those, of those issues, and of course the very difficult situations that have occurred, so there is an underpinning kind of reality to that, of course, but I think in terms of anxiety, those notions do filter through and people, of course, worry about things going wrong, that's very normal. But, again, very hard for us to kind of navigate likelihood and risk as, with our human brains and going into that situation, if you're a pregnant person, you're going to give birth. For many those stories can influence the present in terms of kind of worrying about things going wrong. So, pregnancy kind of related anxiety is very common. It's sometimes called fear of childbirth, it's sometimes called pregnancy related anxiety. Those terms can be used a bit interchangeably and there's also kind of an interaction with OCD as well. And it's also a perinatal concept that unsurprisingly if you have other anxiety problems, it goes along with those too. But yes, I think having lots of exposure to the idea of horrible things happening can, of course, make you feel that those things are much more likely and make your current reality much more scary. That definitely can happen. Rachel: Even if they are the exceptions or at least not as common as they sound like they are? Fiona: Yeah, yeah, exactly. Of course, most people go through birth and labour, and whilst it's might not be the sunniest picnic, it's usually okay, and so on. And, yeah, being a little bit sort of forearmed that things might be challenging can be helpful. There's some really fascinating new work from Pauline Slade that actually, just in the general population, if you in antenatal classes just make people aware of the possibility of complications. If people do experience those things, that can be psychologically quite helpful. So to some extent, knowing that is helpful, but of course, reading about awful things doesn't mean those things will definitely happen. So there's a balance to be struck in terms of that level of information, I think. And of course, things really stand out when horrible things happening into the postnatal period. I mean, going back to the concept of intrusive thoughts of deliberate harm. So most of the women that I've worked with that have read a story or been aware of a horrible case where a mum in particular has perhaps harmed their child in the context of a very severe illness. And that feels like it's very likely and that's very much fuelled their OCD in terms of trying to understand how things like that could happen. Could I do that? And so on. That's quite a common occurrence in terms of worrying about it, whilst the actual events are very rare. Rachel: Yeah, absolutely. I'd like to ask you about some myths, potentially, facts, potentially, that are kind of out there about OCD and the perinatal period, bit like what we've been talking about, all this information that people get kind of thrown at them and also how they might kind of also seek out pieces of information when they're feeling anxious about of what's going on, but also for therapists working with this. Let’s start with, perhaps a straightforward one. Perhaps they might all be a little bit more subtle than that, but how about the idea that everyone gets a little bit OCD around this time? Can you be a little bit OCD in the perinatal period? Fiona: I mean, I think the phrase is inherently unhelpful, and I think most people with OCD would feel quite annoyed to say the least. It's not great to actually kind of minimise what is real distress and suffering. Whilst it's fine, I think, to say anxiety is understandable, phrases like that are completely unhelpful in helping us kind of recognise where people are truly struggling so it's the language I would want to modify in that sense. Rachel: Absolutely. That's really helpful. And how about the idea, which I know, can worry clinicians, that when a mother expresses thoughts of harming their baby or child, this is likely to present a very significant safeguarding concern and should always be reported. Fiona: Yes, this is one of the most common issues that come up in terms of how to navigate what will, you know, 99 times out of 100, will be intrusive thoughts to normalise. And it's all about how you follow up a disclosure. And understanding from clinicians’ point of view that actually there is this spectrum and whilst as clinicians it's really important for us to assess risk properly, it's also important for us to not take that at face value because that can cause harm as well. And that certainly has happened and still does happen, unfortunately, that people are automatically referred for safeguarding processes when it is very clearly unwanted, intrusive thoughts of harm that do not fit in any sense within the person's intention. And there are people that are clear about that themselves, but asking questions, for example, like, are you completely sure you won't act on your thoughts? For a person who's experiencing an unwanted intrusive thought, that's not a helpful question. So, understanding and asking follow up questions about what does it mean to have these kind of thoughts, what do you do when you get them, can give you the right information to understand what course of action to take. I do understand that as clinicians we don't want to get that wrong, and it can feel like the stakes are very high and it can be really alarming if people are disclosing these kinds of thoughts, but it is super important to understand that these thoughts are really common. We think almost all parents will get thoughts of accidental harm. And in most of the studies, about half of parents will say that they have thoughts of deliberate harm, including sexual abuse and violent harm. And these thoughts seem very normal, but it's very important for us to understand, and ask those follow up questions before we know what the right course of action is to take, because it can be as I said really harmful for people if the system almost acts as part of the OCD, kind of like a systemic sort of safety behaviour that, as with all safety behaviours, will stop that person actually gaining confidence that these are just thoughts and they don't mean anything about them. You can absolutely be a wonderful parent and still have horrible, intrusive thoughts because that's all they are. Rachel: And the last thing we want to do is just underline or reinforce that awful shame and distress that people are feeling. And related to that, what about the idea that anxiety in mothers in particular will automatically lead to poor attachment or poor outcomes for their childcare and their relationship with their child? Fiona: Yeah, again, it's really important to be evidence based. Anxious attachment is not the same as being anxious as a parent. And certainly, I think my study is the only one that has used the strange situation, a really robust measure of attachment for mums with OCD. And we found absolutely no difference in terms of secure attachment for mums with OCD and mums who didn’t have OCD. Rachel: And for people who don't know, that's kind of paradigmatic study where parents are with their children and then they leave and then they come back and there's really systematic ways of looking at how the child responds to the caregiver in that situation. Fiona: yeah, so it's a really robust test because it's all about rating the behaviour of the baby. Babies aren't brilliant actors, it’s considered the real sort of gold standard. Whereas if you ask parents about their perceptions of the impact on parenting, that will often be very high. And that's also been replicated in another study I was involved with where mums with various anxiety presentations filled out a bonding questionnaire, really commonly used bonding questionnaire and they were videoed interacting with their babies and in terms of kind of sensitivity, which is one of the precursors and underliers of secure attachment. And whilst the parents with anxiety felt that there might be bonding difficulties that wasn't borne out with the observation at all. So I think it's a really important lesson that we need to think about perceptions as being different from what's actually going on. And certainly my experience with mums with OCD is that their primary concern is about bonding with their baby and their baby's welfare. And sometimes the anxiety and OCD will sort of skew things towards focusing on safety and so on, but the underlying bond is there and what's driving it. Sometimes we're very worried about parents for whom they're much more ambivalent and you know that's where the issue is, but I would say generally speaking parents with anxiety are just trying to do their utmost and so actually that's why the therapy can work so well because it's about trying to utilise that bond to do things in a more helpful way Rachel: So these are the parents that, that love their babies so much, almost to their own detriment because they're loving them in ways that maybe they don't need to because of these distorted perceptions about the harm that might come to them. Fiona: Yeah, I think there's nothing wrong with the love, but it's the behaviours and the way the OCD is, getting them to do all of the checking, not having any sleep and so on, and it's about gradually trying to understand that with the person, using all of your CBT techniques to test out changes and what really happens if I just do that a bit less. But really, the wonder of the work is that the bond is so strong actually, having the bond there is the real sort of glue for the whole work. Rachel: And how about sort of taking that step further beyond that sort of immediate bond? Is it true that children of anxious mothers will inevitably, and that's very labelling, isn't it? Anxious mothers, but children of anxious mothers will inevitably grow up to have an anxiety disorder, or that they will be damaged in some way? Fiona: Yeah, and there's absolutely no inevitability about that. There are undeniably studies showing increased risks of anxiety and depression for kids of parents with anxiety and depression- and the reasons for that are going to be complex, but there's no inevitability. I think that's really important. So we're looking at a kind of a relative increased risk. And I think some of that will be a sort of overall genetics vulnerabilities and so on. But some of that will be perhaps parenting style and so on. And that's so actually engaging with parents at the earliest stages because often parents will come into treatment for that reason and being very worried about the impacts on children and so on. Again, a lot that we can do and getting treatment for your anxiety will teach you the skills to understand anxiety in your children. It's very cool. That's kind of a real double benefit there, I think, and that often is quite an explicit part of the work that parents actually do want to be able to kind of better, create a better environment for their kids. So I think there's still, there's no inevitability about things, but the longer that you can be free of your anxiety problem, I think that's likely to be the best for you as a parent and for you as an individual, and for your kids too. Rachel: Perhaps what we need Fiona is a RCT on whether it's more damaging for children to have a clinical psychologist as a parent or someone with an anxiety disorder. But I keep telling my kids I'll pay for the therapy if it comes to that. Fiona: Yes, no, maybe let's not look into that too closely. Rachel: so final myth or fact that does occupy therapists a lot, I think in this kind of work is, is it irresponsible to do exposure therapy when someone's pregnant? Fiona: Right, this is a very recurrent topic at this point. Therapist anxiety is a real thing, right, and we do all experience it, and we're now working with our patients, even outside pregnancy, and they say, oh, I hope this thing doesn't happen. Sometimes there is a little echoing thought there as well, it's like, oh, I hope the bad thing doesn't happen as well, but doing this is has a different purpose and as with as we were talking about lots of things are heightened in pregnancy so I think those therapist beliefs can loom a lot larger. And there's anxiety from therapists points of view and sometimes from system points of view that if we kind of get people to do exposure, that might somehow cause harm. And it's really important for us to engage with that and think, well, that's an important consideration always, isn't it? So we do actually need, again, data on that. What could be the mechanisms of harm? What do we actually mean by exposure therapy? And I think when we're sort of getting into it, there's an assumption there that exposure is getting people to do awful things that make them feel terrible and then we just make them go home and hopefully our therapy isn't like that. We're setting a framework, aren't we, that people are kind of doing things to experience life as it is. And the idea of that is that will then help them with the anxiety that they are bringing. They're coming to our sessions to do an evidence-based treatment because they're already anxious. There's already a high level of anxiety there, and that's often a neglected part of the argument, even though it's very key that people are coming for help because they're already anxious. We're not actually picking people off the street and asking them to do these things for no reason. I've recently completed a trial of exposure based treatment in pregnancy and the participants responded to the treatments really as you would hope and expect, that they felt apprehensive about doing some of the exposures, but did it, learnt, some of the quotes from the participants were really a textbook in terms of kind of, it was by doing that, that I really found out that my sensations were safe and they were just part of my anxiety. Reliving in PTSD, that was really difficult, but it was like, I'd gone back in time. I understood new things about the experience and that helped them then to have a better pregnancy and less anxious pregnancy as they went through. And so we asked them a lot about that experience, of course, to understand whether there were any negative effects and so not finding it aversive, not wanting to do it. I mean, that's our job as therapists working with anxiety, isn't it? We kind of need to approach that. Rachel: No one comes to our session skipping with joy because we're going to ask them to do exactly what they want don't want to do… Fiona: Exactly. And it was mirrored from the therapist as well, those little voices were there of kind of, I knew that I needed to be confident delivering this, in order to demonstrate that for my person. And really having to remind oneself of the model and so on in order to do that. And I think that's okay. That's part of our, you know, we have to keep self-correcting and reflecting as therapists. And these were incredibly skilled and experienced therapists, and it was a good kind of, again, lesson that these things, we're human too, and these things do happen. I think we can say that it's safe and it's really important to do and it's effective as long as the person wants to do these things and are motivated and feel like it's the right time. Often there's a lot going on for people in pregnancy. I think that was more of an issue in terms of delivering treatments that often people are dealing with work or there's housing difficulties and can we actually book in sessions for the next few weeks in order to be able to do this properly and well. These are the real considerations, I think, having enough time and they're looking after the little ones, how do we do this, do we do it online? All of the logistics are really key to delivering treatment well. And we've got to pay attention to those issues which are more prominent in pregnancy. But I think when the person is motivated and able to do it, it works really well and we shouldn't withhold a treatment because the person is pregnant and we are gaining evidence that it's helpful and it's an evidence based treatment during this time as others. Rachel: I think that sounds like a really helpful corrective as well, as you said, that these people are suffering anyway. I know we often talk about OCD as a kind of bully, don't we? And we would encourage people to stand up to bullies. And that doesn't mean it's not going to be hard, but you don't stand up to them they're still in the playground every day and you're still facing that distress and that uncontrolled exposure and distress in your daily life. Fiona: Yeah, and if someone says, look, I would really like to work on this now before my baby comes and we just, we say, no we're withholding a treatment. We need to have a really good reason for that, and I don't think we do. It’s in some services that I've encountered they’ve, we don't do any treatment in pregnancy, we don't do exposure in pregnancy. Sometimes exposure is getting the person to be able to sit on a seat so that they can use a train. It's like, I think we just really do need to kind of dig into what we do mean by these things and whether it's ethical to withhold a treatment that works for someone that wants it. Sometimes we do modify things. So we might not do the full kind of anti OCD experiments with a pregnant person. I think that's okay as well, interesting what where to stop and so on. But it is a negotiation. We need the person to be on board. So I think thinking about what would a pregnant person at this stage of pregnancy be able to do, that's what we're aiming for. What's going to help you with where you're at now, so I know, I've talked a lot about this because it's such a key issue, it still comes up all the time, we need better guidance. Rachel: Absolutely, it sounds like your trial is a really big step forward in that as well. You may be aware that on this podcast we have a challenge, so we ask our guests to give us a brief explanation about the particular presentation they work with, how it develops and is maintained, without repetition, hesitation, deviation, boxes, arrows or other visual aids which can be tricky for CBT therapists. So we've recently asked, as we've mentioned already, your longtime colleague and collaborator Paul Salkovskis to do this for OCD. So he did it pretty well, as you might expect, having written the model, but maybe you can do a better job, and maybe, there are some sort of specific factors you want to add in around mums in this perinatal period and OCD. Over to you, challenge extended. Fiona: Right, so just to make sure I've understood, giving you an overview of an entire formulation of a particular presentation. Without hesitating or referring to any boxes and arrows. Rachel: Yeah, but what the listeners don't know is that we can edit out hesitation, so don't worry too much. Fiona: Well, I will go with what is the key presentation of intrusive thoughts of deliberate harm in the postnatal period. It’s not uncommon for a person to experience these seemingly out of nowhere. As the baby is handed to them in the delivery room. Because OCD is a brilliantly apt detective for knowing what is the worst possible thought that a person could have at this time. And that's what makes it so devious because it's a time of joy and a time where you might not be expecting these kind of thoughts. You might have gone through a horrible birth, but you might be there with your baby and an OCD thought will pop in. But of course, that makes perfect sense to us in understanding the model because due to those situational vulnerabilities, that's what makes that thought really stand out, and of course it really does. So we know, of course, the thought itself is no problem at all. These thoughts are very normal and very common in the perinatal period, amongst birthing parents and non-birthing parents, they're super common. But if you're not aware of that, that thought might stand out even more. And if you think that thought means, my goodness, I am about to do something awful, this is it. What sort of a person has this type of thought? Who could I even say about this? I'm going to hand the baby back over to my partner. That's where the problem can really begin. And OCD becomes very pernicious like this and surrounds the problem with shame. And we know that there's lots of that going on for new parents, you're learning on the job, you're often being told by all sorts of people what to do and how to be. It can be very difficult to find your ways, it's another vulnerability factor. So having these horrible thoughts, and having that now your radar going round for, well, I better look out for these kind of thoughts, more of them tend to pop up. It then reinforces this idea that, my goodness, perhaps I am an awful parent. What kind of parent does that? Perhaps I need to go away and think about all the terrible things I've done because there must be some kind of reason for this. And so on and so on. There's much more sort of fuel. Better not spend time with the baby. Perhaps I'll let my partner do that all important first bath because, gosh, if I was to do it, I might do something terrible. Now I've got this clue that in this new situation I've never experienced before, something has been activated from my deepest, darkest soul, and poor people are left stuck with these horrible thoughts. You can see how then the behaviours would reinforce it. Super upsetting. Where do you go to with this type of idea? Can you talk to your antenatal group? It can be all a bit tricky. So lots about the situation can be in the ways we're very familiar with how devious OCD is. In this particular situation, it makes sense that this is very common because we don't talk about these things in our antenatal groups more generally, although we could, that would be a very helpful and very cheap way, I think, of, perhaps preventing for some people the onset of these problems but actually having that information would be super helpful, and of course the treatments can work so well because we tackle these, all the avoidances, we tackle that meaning and help people move on from this. Rachel: That was brilliant, and not only was it very clear, but also actually, genuinely, that was, I find myself quite moved when you're talking about that first bath because it really highlights to me as a parent what this can rob from you as a parent. There are really small but absolutely precious moments in life that add up to the joy of parenting. Fiona: That's right. That's a really important point. And I think that's why it can take people a long time to recover from these experiences, not in terms of intrusive thoughts and feeling that you might act on them because in a way the treatments work so well for those kind of things. But there's this sort of legacy of this was a really special time and opportunity that has been robbed from me in various ways. And so quite often we're working with people in the medium and longer term to help them come to terms with some of those moments. And often it hasn't robbed everything. I think that's an important point to make. And also, if you haven't got OCD, sometimes those moments are a little bit tricky as well. And things are in more of a spectrum too. Rachel: I’m forgetting all the screaming that went on with the first bath. I'm sure this is what selective memory does. It's fortunate that I was sleep deprived probably at the time. Fiona: that's the thing, isn't it? It's generally, there are moments, but there are definitely other moments as well. So, but yeah, that's where talking about things can, I think, help process all of that too. Rachel: And we know, as you said that, the treatment for OCD is very effective, clearly not for absolutely everyone. there's always places to go in developing these treatments, aren't there? But it's a really effective treatment for OCD. In perinatal OCD, is it as effective and is it equally effective for everyone across diverse groups and populations? Fiona: These are really good questions. As I said, there are not loads of treatment trials, but the one that I did show that was it's as effective in terms of, I mean, it was a pilot trial, but the effect sizes were similar to kind of OCD at other times. Research has a diversity issue, I think, and that's OCD, perinatal OCD is no different from that, so we need better answers to that question as to whether it's as helpful for people across groups. I think there are differences, in terms of how appealing services are, so who's coming to services is a big issue. So whilst we have this effective treatment potentially, I don't think it's being, it's as accessible across diverse groups. So we do need to do better within perinatal OCD and within general mental health services to fully answer that question. Of course, good practice is to adapt treatment as much as possible to the person in front of you and work together to, or work as a therapist to understand and bridge any difference and kind of think about the context the person is in. But yeah, it would be great to have more information about that. One adaptation so that in the trial was to do intensive therapy postnatally and in the pregnancy trial, I did intensive and weekly therapy and they both worked well, but I would say in the postnatal period, so intensive treatment, it's the same as the regular treatment but doing it in a shorter period of time. So essentially, we had four sessions of about three hours each that were spread over two weeks, and that worked really well for postnatal women in that context. So as we have been talking about, it's a busy time. It's very hard to find time for yourselves. And I was, reflecting at the time of that trial on our standard treatment model, which is where we ask someone to come to a particular place- this was pre covid. I asked them to be at this place at this particular time with their baby, or not, for an hour a week for three months. And the idea of that when I was at that stage would have made me want to cry, really. Rachel: The idea of being able to wash my hair at the same time once a week at that stage. Fiona: yeah, exactly. So we got really good feedback for that trial because we tried to do as much as we could at home, and it's not always possible, but that is the ideal or a mixture of at home and in the office. But having these long sessions, it felt manageable for people. They could organise childcare for four afternoons, or as opposed to for three months. So I think thinking about the delivery and implementation is really important for the perinatal period, but for OCD, where getting momentum is really key to change that model worked really well, so I'd highly recommend that. Rachel: Those intensive treatments and remote treatments as well and all these innovations are, seem really important across the board in lots of different problem presentations. I guess I wonder how this, if you've got any thoughts about how this might translate into your average psychological therapy service that isn't doing a trial, isn't resourced to do it in that way. Do you think this is possible in the future? Fiona: Yeah, so the pregnancy trial we ran through Talking Therapies but it is an issue in terms of the model. You have to do lots of negotiating, and it wasn't, always easy because I think there's an anxiety if that person cancels, that's three hours contact hours that are then not filled and so on. It's something that needs a bit of thinking about. So the Perinatal Positive Practice Guide is a wonderful document that sort of highlights some of this implementation stuff in terms of needing more flexible cancellation policies within perinatal and so on. And obviously within specialist perinatal services, that's the bread and butter, it's more configured around that, perhaps there's more sort of flexibility to do that, but yeah, it's an ongoing question, it's not easy, so easy for these, they're wonderful services but to do, to be a bit more idiosyncratic and adapt in that way is genuinely more tricky, I think, so that’s the challenge. Rachel: And I think, we're just, we're so socialised into thinking about therapy is once a week for an hour a week, aren't we? And really there's not necessarily a legitimate reason why that is the best way to deliver any therapy. Fiona: Yeah, and there's an increasing evidence base for time intensive models. And I think that there are pros and cons. I think they work as well, but I suppose it's having more choice for people. That's the ideal. I think there's no point sort of forcing people into an intensive model where that wouldn't work for them with their other commitments or so on. But it seems like it's a good adaptation to have available, if possible, particularly in this context. Rachel: Talking about adaptations and therapy, so what does a, what's a typical course of therapy look like? What are the core elements? And you've already mentioned a few things that we might adapt for this period, but what are the core elements? What might be the typical/ atypical pieces if you like around perinatal OCD? Fiona: Yeah, so it’s always context dependent, isn't it? So I think very familiar in terms of CBT for OCD, but the parenting element is usually weaving that through and through. So the majority of people, their OCD will be interacting or be orientated around the baby, but not for everybody. So there are certain, certainly a very small subgroup of people for whom, their OCD is just really nothing to do with it. But because OCD is very consuming, there is an impact. So I think being very sort of sensitive to that in terms of goals and what the person's sort of wanting to achieve is really key. There is a question about how much to involve babies in treatment. It tends to be, I think, really helpful if you can have the first few sessions without the baby there and getting the person really clear with the understanding the model, theory A, theory B, getting things kind of set up. But then after that, trying to make everything as integrated with real life as possible, which for most people will be about looking after the baby or doing tasks with the baby or going to places with the baby, it's just really putting things into the current context, really. Rachel: And theory A, theory B for those who are new to this, the idea that OCD or the problem is, Fiona: Yeah, so it's a key tool in the armoury, but this kind of real paradigm shift, it really, I think it's the kind of basis for the whole treatment, really. So once you've kind of done your formulation, and as we were talking about in the little vignette there, so understanding the problem and what's at the heart of it is really important, or gaining a shared understanding of what's currently driving it, but then you as a therapist are offering an idea to test out in the rest of the treatment that perhaps, rather than theory A, the problem is that you are a horrible psychopath, actually the problem is that you're terrified of that idea. And understanding the difference between those two is treatment in itself, I think, and really understanding and then absorbing the idea that if this is an anxiety problem, that probably does make sense of why instead of trying to do harmful things, I'm actually trying to do the opposite. So it really gives you such an important structure for a new understanding, taking things through behaviourally, so that makes sense that if you're terrified of this, it's an anxiety problem, what you need to do is actually less of that, because that's what will help with your anxiety which is the key problem here. And getting the person to explore that themselves and, in various ways, thinking about why they believe what they do, what's in their history that might fit better with that and then, what are they doing that might be kind of making that anxiety worse? And then therefore, what do they need to do to make it better? Everything sort of flows from that. So it's a good question, Rachel. That basically is the whole treatment. Rachel: and then you're piling in the usual behavioural experiments. Fiona: Yeah, absolutely. So it's really important to use that understanding to do things differently. Sometimes it's curious, I think, especially perhaps interacting with our stateside colleagues where they have a slightly different model. We do ERP within the context of CBT, but it is about belief change and how we integrate those things. It's really important to actually do things differently. It isn't just about challenging thoughts in an abstract way. Rachel: So not just ERP, Exposure Response Prevention, but actually thinking about those cognitions. Fiona: Exactly. So theory A, theory B really lays the foundation for what we're then going to do next behaviourally. If theory B is true, that this is an anxiety problem, then you can be next to your baby, you can have all the knives drawers open in your house. You can change your baby there and that will ultimately seem probably a bit absurd. But OCD will have perhaps stopped that person from doing that. So, it isn't just about kind of habituated to anxiety. Paul has this wonderful phrase, Paul Salkovskis says, it's finding out how the world really works. And that's a cognitive process. That's a cognitive affective process because it really kind of gives people that lived experience, and that sort of aha moment, ideally, that actually, oh, what I believed then, it was too scary to even test out, but in doing that, its fine. Rachel: And you mentioned earlier something about maybe not going to the anti OCD piece. Do you want to say a little bit more about, about what that means? Fiona: Sure, in order to feel confident about things, we usually probably want to go a bit further than opportunities might present themselves in life. And given that we can't prove that we won't do something, let's go with that example, a person who might be worried about stabbing their baby or what have you, it's really hard to prove that something won't happen. But of course, generally in life, we're not trying to do that but because we don't feel it's necessary. So we're trying to get to the person to a point where it's like, this doesn't really feel necessary because I just know in that way that I know I'm not going to push someone into the road when I cross the road. It's not something I need to sort of process. So, we ask people to do a bit more then they might do on average, so sometimes it's very common for parents with this particular problem to say, avoid chopping food near the baby, what if I did something impulsively? So whilst we definitely want them to be able to do that, we want them to feel really confident so we're like, okay what we're going to do with this? We’re going to chop food right next to the baby and when I say, get all of the knives out, get the absolutely massivest one, even though you're only cutting a little tiny carrot or something like that to build on that confidence. So we, what we call anti OCD experiments are really kind of pushing back against the OCD and just saying, right, okay, what I'm going to do is take this to such a level that I'm showing up OCD for what it is. It might be very inconvenient to use this knife, so I'm not going to do it on the regular, but I can if I want to. And so on. And sometimes maybe that would be the only knife there. So we really want to make sure that whatever life chucks at us we feel we are able to do it. In contamination OCD, it might be not washing your hands after going to the loo would be a really common one in general, that's probably not a bad thing to do. But every now and then you might be in a situation, I don't know if you go to festivals or perhaps you're in a service station and the taps aren't working and it's like, you're just going to have to live with that situation and it's okay. So you want people to know that there isn't this line, OCD says, right. All right, okay, you can have that one, but you can't use the really big knife, or ooh, this is where the line is, and life isn't like that, so we really encourage in the opportunity of therapy, people to go as far as possible. And that's within common sense grounds, as it were. So we're not ever doing anything harmful, of course, to a baby. But we might say, it's really important that you're able to, like change your baby when you go outside. And probably us parents have all been in that situation where it's not optimal. You might find yourself in, probably in similar, in the motorway service station. Or, actually they're usually quite good actually. But some other equivalent where you just have to get on with it. And so we want people to have as much experience in the bank that's generalisable that they can just get on with it, if they have to. And then it makes it much more straightforward to choose the path that you want to be on, rather than OCD choosing it for you. Rachel: Bit like exposure to that massive spider in spider therapy that you might not normally be coming across in your day-to-day housecleaning. Fiona: yeah, exactly. Rachel: But you said that you might, there might be occasions in the perinatal period where we wouldn't go to the nth degree on the anti OCD sort of pathway. Fiona: possibly. I mean, particularly things like contamination experiments in pregnancy. I mean, again, having been pregnant or knowing pregnant people, you modify things a bit, you might wash your food a bit more and that's okay. And I think it's fine to do those kind of experiments where, not washing something, but going and kind of doing a full kind of toilet contamination experiment. It would be quite in the negotiation with people. Probably isn't totally necessary at that point. And, there are, there is a special context, so I think that's what I mean of kind of there are slightly different parameters on it, but you might want to say, this makes sense for now, we want to, you to be doing what your friend is able to do within your group, the average person, but actually postnatally, we'll save some sessions to do some of this stuff so that, as said, you can deal with whatever service station that you're at. Rachel: So see, you'll be lurking in the delivery room, Fiona, with your hand down the toilet. Fiona: I don't know, I'll give them a few weeks off at that stage, but something like that. Rachel: So we may have talked about a few of these particular issues that come up most frequently, but you've been now doing this for a while. I'm not going to age us, Fiona, but we've been at it for a while now. And you do have extensive experience of teaching, supervising and applying the models in this perinatal period. So where do you find therapists get stuck? What are the most frequently asked questions or the trickiest issues that come up? Fiona: I think, yeah, contamination stuff can be really tricky. Sometimes the versions of OCD where it's very internal and ruminative and unverifiable. So, there are some, within perinatal ones, they're less common, but they do come up. So things like, have I given my baby the wrong name is relatively a common one, so that, really trying, getting into those concepts of what's right and wrong and so on, and people worrying about having done something which might cause damage years down the line. So again, it's very ruminative, and it's not uncommon within OCD, but everything is ramped up because of that responsibility piece, and people can get really sort of distressed and it can be quite difficult to get at some clear blue water with people in terms of the treatment of theory A, theory B. So those are quite, they are quite tricky forms of OCD, I think, when it's very internally referenced and, and driven. So yeah, I think those are common ones. And then ones where the person is very contamination focused, there's been a few that I think have been really sort of fuelled as well by the pandemic. It was a very difficult and strange time for us all, where people have been, it's been obviously very kind of reinforced in terms of external threat and needing to keep things safe but actually then people still being stuck within that. So there being difficulties in delivering treatment to people because of the overall situation, but also that sense of threat and probably less dissonance, I guess, to work with in terms of kind of, I need to keep my baby safe against the world. And kind of maintaining those beliefs that the world is a hugely threatening place and of course, at a very extreme end, that's really difficult and really problematic, babies not people not going outside, there's being lots of stuff going on at home. Rachel: And in that kind of brings to the table, this is wider system that people are kind of part of, aren't they, dads, birthing partners, family, and those kind of pressures that can be reinforced by the people around them as well. But also I guess we have talked a lot about mums, or, birthing people in this podcast, but I guess there's a lot of stress around also for birthing partners, for dads in that perinatal period. And I think you've looked a little at this and how this can be impactful within the family system. So, do dad's/partners need any special help or consideration in this period? Fiona: Yeah, absolutely. it's a time of increased risk as well for Dads. Intrusive thoughts are very normal in birthing and non-birthing parents because of the way services and so on are kind of configured, there's less detection, I think, amongst, the non-birthing parent and it can be more difficult to plug in and sort of understand that context as well. Whilst it does happen, yeah, I think dad's non birthing parents are less well served. But yeah, of course, because of the context, it's similar for both parents and there's anecdotal evidence, not so much research also about grandparents as well. But, probably to a lesser extent because of the being a step removed and not having all of the biological factors as well but absolutely, I think because of the vulnerability piece and because of the responsibility piece and so on and how common intrusive thoughts are at the time of increased risk, as well. Rachel: So we need to not forget the others Fiona: Yes. Rachel: So then thinking about, ourselves as therapists and self-reflection, the stuff we bring into therapy sessions, there can be challenges around this work, I guess. And sometimes we have to challenge our own assumptions about what we're doing. Sometimes we have to look out after ourselves at particular vulnerable periods. What about therapists treating OCD, for example, whilst they're pregnant themselves or they've got a partner who's expecting or they're co-parenting small children. What kind of things might therapists need to consider with respect to self-care and also kind of managing their own assumptions and how they might impact on therapy. Fiona: Yeah, I think it's always important to check in with those things, but I think something particularly heightened about perinatal period. There's so much lived experience, and as we've kind of talked about throughout, it's all so relatable, I think. It's why it's such a wonderful area to work in, that, all of that makes sense. And I think, if you are pregnant or trying for a baby, it does bring up things for you and, if one of the kind of main drivers of OCD at this time is about causing harm, allowing harm, these things can really chime. So I think it's really important to reflect on whether things are coming up for you, how comfortable do you feel taking on this case or working with this particular form if it chimes with your own experience either present or past. I think it's always fine as a therapist to say, actually, I just, for this particular person, I'm going to take a pass on this one and work on the next case that comes in. And I think sometimes we can be surprised, and I think it's good to be reminded of ourselves as human beings as well, it's not, you can be the most kind of hardened therapist, but sometimes certain experiences will just get to you and often, with our perinatal OCD clients, there are very good reasons why people are very tuned in to harm and loss and so on. And sometimes it's those background factors that can really chime with us. And so we need to be able to think about that whole picture. And I said, it's really fine if for whatever reason that's just not for you right now because although we have talked about the formulation and so on, we're actually talking, it's the whole picture that is very important of making sense of things, why is this person feeling as they do right now? Rachel: Yeah. And I guess on that theme of that bridge from the professional to personal, I guess we learn a lot from our patients too, don't we? Kind of what we take away as professionals, but also as human beings. And I'm wondering if there are things that you've learned from your patients that have made a personal difference in your life or the focus of your work. Fiona: I think, again, it's one of the great privileges. You learn from absolutely every person that you work with, I think. And that's why it's just such a wonderful job. And in terms of specifics, like how to deal with things, when the worst happens. I'm often really in awe of the people I've worked with. Whether I could translate that to things that I can do differently is perhaps another question, but understanding how amazing people are, even in the depths of very difficult experiences, it's very humbling. And I think gives you hope when things aren't going your way for whatever reason. I find that a great source of comfort actually just to think there are ways and having that privilege of connecting with people and trying to understand with them their strengths, is a great source of hope, I think. Rachel: And you've got two gorgeous daughters yourself. Has being a mum changed how you've approached the work? Or has the work changed how you've approached being a mum? Fiona: I actually became pregnant during my trial. And so at the beginning of the trial with the first few people I was working with there, I wasn't a parent and became one during that process. So that was really interesting in itself. It's helpful for behavioural experiments as well but of course, gave me such a lot of insight, I think, that I could see from afar, of course you don't have to have experienced everything that your client group has. But when I was normalising, like, this is really hard, I really knew that up to the depth of my being, in a way that I didn't before, I think. So I think it gave me more authenticity, perhaps, and solidarity, and understanding the nuances of what's it actually like to be awake at four in the morning trying to work out breastfeeding and in the context things. So I think it just gave me more, even more, respect for the parents that I work with, as well, and having more anecdotes to draw on, and I got intrusive thoughts as well. I often mention that in teaching. Having spent the preceding several years kind of researching and thinking about intrusive thoughts, I was very pleased to actually get some really terrible ones myself as I brought my baby home. I thought, hang on a minute, I know what's going on here. These are really awful, but yeah, I'm very lucky that I've got a context. Rachel: You, you were forearmed in, in that case. Fiona: Yes, yeah, still, it's interesting. Still have, you have that emotional reaction because they're horrible images, but I didn’t have the awful meaning Rachel: I can identify with that. Absolutely. 100%. yeah. And I guess, well, we're not implying that you need to be a parent to do this work, obviously. There are phenomenal therapists who don't need to share our experience that our clients have, but it can add a different dimension, can't it, to the work. And as you say, some useful anecdotes, perhaps on a more superficial level for me being pregnant and doing therapy, just managing toilet breaks was it was an issue. Fiona: Yeah, exactly. And then, I think appreciation of all the logistics as well. I think it's very hard returning from maternity leave and having, there's multiple roles and even just being in the right place at the right time. Rachel: You're very active still, obviously, in your research, and you've talked in this podcast a lot about different pieces of work you have ongoing at the moment. What are the next big challenges, do you think? What are the horizons for the research, the therapy, for dissemination of the therapy? What's going on in your world? Fiona: It would be really good to have more evidence about treatments, particularly in pregnancy, so we've made a start with that, but kind of more definitive trials, and say more sort of diverse groups as well, and I think, yeah, trying to address some of these issues that we touched on earlier about access to services, I think is as important as the kind of what, obviously it's very important that the treatments that we deliver, but there are issues with that in perinatal. So I see that as the biggest challenge and that these inequalities, across maternity and mental health. As mentioned earlier, there are some really tricky forms of OCD and, well, CBT works beautifully for many people, but not for everybody, so I think kind of continuing to try and refine the models and treatments for those who don't get as much benefit would be really important. There's still lots to do, and I think working on the parenting piece too, so that's the other main thread that I'm following at the moment as well, as to whether we can help people, support people and enhance their early parenting skills, as well as treatment for their kind of OCD and difficulties, because it's so intertwined with becoming a parent. I think that's a very fruitful, potentially really fruitful area. If we can support the parenting, we might actually then be able to indirectly address a lot of the things which are driving the OCD. So that lack of confidence and feeling, I might be a bad parent, if we can actually give people some concrete skills to enhance what they're already doing. Because I said they're usually incredible parents. I should have said, that's one of the things I've learned from my parents. How to do things really well actually, but helping them realise that more could I think again really enhance our current treatments in the perinatal period. That's always been a question or, how do we really integrate treatment for the parents own mental health as well as treatment and to support their early parenting. Rachel: I can hear from what you're saying just why it's such an exciting place to work because you're influencing life, not one person, but a whole family system there. Fiona: Yeah, hopefully, yeah, it's really warming when things go well and people are putting things into practice and sometimes they'll email you back with, pictures or things that they're able to do with their new little one and it's just wonderful. Rachel: So if people want to learn more about your work, access training, et cetera, or want they get involved, how can they learn more about that? We'll obviously put links to your books and any papers you can recommend and the show links, but what steps forward would you recommend for people who want to get more into this sphere? Fiona: So there are lots of resources. One of the first ports of call would be the maternal OCD website. So that has lots of research resources and lots of patient facing resources, including an infographic that we co-produced together. And there's also an animation coming out about intrusive thoughts that we have worked with Maternal OCD with. So just to give a bit of background on them that’s Maria Bavetta and Diana Wilson who are people with lived experience who set up this charity to raise awareness. So as I said, when I started working in this field, it was a very little known problem and they've done absolutely fantastic work in raising the profile of maternal OCD. And we've actually produced lots of training events and things together. So that's a great port of call. There are also formal trainings available, things like OCTC run workshops on perinatal OCD and other perinatal mental health problems. If you are coming in as a practitioner in specialist services, there's an upskilling program as well to access, which is highly recommended that also has formal training and supported clinical work as well. So that's a wonderful resource, but there's more and more coming through to train the perinatal workforce. So the Talking Therapies Competencies and Positive Practice Guide are just fantastic summaries of where we are with the evidence too. So loads of things to access if you're new or very weathered within perinatal, there's always, stuff going on in excellent training. Rachel: I often find a good old self-help book is one of the great places to start. And of course, you've got one of those, went on with Victoria and Paul Salkovskis and various books you publish, which are so well written and so accessible and just really insightful. Both for patients and for therapists, I think. Fiona: Thanks Rachel. That's very kind to say, it feels like those kind of things, even though they're obviously not the academic kind of products, but I think you could make a case of those make the most difference. And it's really nice when people get in touch or come up to me at a conference or lived experience event. And they say your book really helped. And it's a team effort. It's Paul's model but yeah, that's a really nice experience. We do have a perinatal specific one on maternal anxiety, which covers OCD and lots of other presentations, which, as said, often kind of go together as well, so another self-help one in the arena there. Rachel: So in true CBT fashion, we're going to summarise and think about what we're taking away from this session. I guess the question is, what key message would you like to leave folk with regarding this work and the perinatal period? Fiona: Perinatal OCD is, can be a really tricky problem for people, really impacts on parenting, but the treatments are very effective and it's a wonderful time to work with people and as I said you can benefit or you can support people to be the best parents they can be and as a therapist you get so much from that too. Rachel: Fiona, thank you so much. It really has just been a delight to talk to you about this work that you're invested in and done so much amazing stuff that will really help people. I'm sure lots of people listening to this will have taken loads away. So thank you so much for your time. And as always to our listeners, thank you for all the work you do and until next time, look after yourself and look after each other. Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. 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